Anthrax is a serious, potentially fatal disease that can present in four distinct clinical patterns depending on the route of infection (cutaneous, gastrointestinal, pneumonic or injectional), so that effective strategies for prophylaxis and therapy are therefore required. Anthrax is a serious disease, requiring effective strategies for prophylaxis and therapy. This review addresses the complex mechanisms of pathogenesis employed by the bacterium and describes how, as understanding of these has developed over many years, so too have current strategies for vaccination and therapy. It covers the clinical and veterinary use of live attenuated strains of anthrax and the subsequent identification of protein sub-units for incorporation into vaccines, as well as combinations of protein sub-units with spore or other components. It also addresses the application of these vaccines for conventional prophylactic use, as well as post-exposure use in conjunction with antibiotics. It describes the licensed acellular vaccines AVA and AVP and discusses the prospects for a next generation of recombinant sub-unit vaccines for anthrax, balancing the regulatory requirement and current drive for highly defined vaccines, against the risk of losing the ‘danger’ signals required to induced protective immunity in the vaccinee. It considers novel approaches to reduce time to immunity by means of combining, for example, dendritic cell vaccination with conventional approaches and considers current opportunities for the immunotherapy of anthrax.

Environmental contamination with Bacillus anthracis spores poses clear threats to livestock that play key roles in the economies of pastoral communities. Regular monitoring of contaminated sites is particularly important in anthrax-endemic parts of the world, such as Kars province in eastern Türkiye, where the Veterinary Microbiology Department of Kafkas University has conducted an anthrax surveillance programme for over 30 years. We reviewed the microbiological results of 232 soil samples collected during 2009–2023, from sites known to be contaminated with B. anthracis spores following burial or butchering of infected animal carcasses. Twenty-five contaminated sites in 16 villages were studied. Samples were taken from a total of 61 different positions within these sites and viable spores were detected in 136 (58.6%) of the samples examined. Of the 96 samples from which spores were not recovered, subsequent samples from the same positions proved positive on 21 occasions. Using a standardised sampling plan, it was discovered that samples taken 1–2 m on a downward slope from the centre-point of contamination had higher (p < 0.001) spore concentrations than those taken from other positions. Although spore concentrations at some sampling positions varied over time, the overall values remained stable. This finding contrasts with observations in other parts of the world where spore concentrations tend to decline with time and may reflect regional differences in soil composition that permit more prolonged spore persistence. Concentrations of >100 spores/g soil were found in 10 (66.7%) of the 15 samples taken 10–13 years following a contamination event. These results demonstrate the longevity of viable anthrax spores in the soil of agricultural environments following decomposition of infected animal carcasses, and therefore the need for prolonged bacteriological monitoring of contaminated sites. Furthermore, they underline the importance of appropriate decontamination, as burial on its own does not eliminate all spores.

Environmental contamination with Bacillus anthracis spores poses uncertain threats to human health. We undertook a study to determine whether inhabitants of the anthrax-endemic region of Kars in eastern Türkiye could develop immune responses to anthrax toxins without recognised clinical infection. We measured anti-PA and anti-LF IgG antibody concentrations by ELISA in serum from 279 volunteers, 105 of whom had previously diagnosed anthrax infection (100 cutaneous, 5 gastrointestinal). Of the 174 without history of infection, 72 had prior contact with anthrax-contaminated material. Individuals were classified according to demographic parameters, daily working environment, and residence type. All villages in this study had recorded previous animal or human anthrax cases. Stepwise regression analyses showed that prior clinical infection correlated strongly with concentrations at the upper end of the ranges observed for both antibodies. For anti-PA, being a butcher and duration of continuous exposure risk correlated with high concentrations, while being a veterinarian or shepherd, time since infection, and town residence correlated with low concentrations. For anti-LF, village residence correlated with high concentrations, while infection limited to fingers or thumbs correlated with low concentrations. Linear discriminant analysis identified antibody concentration profiles associated with known prior infection. Profiles least typical of prior infection were observed in urban dwellers with known previous infection and in veterinarians without history of infection. Four individuals without history of infection (two butchers, two rural dwellers) had profiles suggesting unrecognised prior infection. Healthy humans therefore appear able to tolerate low-level exposure to environmental B. anthracis spores without ill effect, but it remains to be determined whether this exposure is protective. These findings have implications for authorities tasked with reducing the risk posed to human health by spore-contaminated materials and environments.

The causative agent of anthrax, Bacillus anthracis, evades the host immune response and establishes infection through the production of binary exotoxins composed of Protective Antigen (PA) and one of two subunits, lethal factor (LF) or edema factor (EF). The majority of vaccination strategies have focused upon the antibody response to the PA subunit. We have used a panel of humanised HLA class II transgenic mouse strains to define HLA-DR-restricted and HLA-DQ-restricted CD4+ T cell responses to the immunodominant epitopes of PA. This was correlated with the binding affinities of epitopes to HLA class II molecules, as well as the responses of two human cohorts: individuals vaccinated with the Anthrax Vaccine Precipitated (AVP) vaccine (which contains PA and trace amounts of LF), and patients recovering from cutaneous anthrax infections. The infected and vaccinated cohorts expressing different HLA types were found to make CD4+ T cell responses to multiple and diverse epitopes of PA. The effects of HLA polymorphism were explored using transgenic mouse lines, which demonstrated differential susceptibility, indicating that HLA-DR1 and HLA-DQ8 alleles conferred protective immunity relative to HLA-DR15, HLA-DR4 and HLA-DQ6. The HLA transgenics enabled a reductionist approach, allowing us to better define CD4+ T cell epitopes. Appreciating the effects of HLA polymorphism on the variability of responses to natural infection and vaccination is vital in planning protective strategies against anthrax.

During construction of the Baku–Tbilisi–Kars railroad between Kars City in Türkiye and Tbilisi in Georgia, blasting operations in an anthrax-endemic region disrupted a burial pit containing carcasses of cattle that had died of anthrax. Railroad workers expressed concerns that release of this material could result in them developing anthrax infection. We therefore undertook a seroprevalence study six months later to seek evidence of exposure to Bacillus anthracis spores. We used an optimised Enzyme-Linked Immunosorbent Assay (ELISA) to screen serum for antigen-specific IgG antibodies to the anthrax toxin subunits Protective Antigen (PA) and Lethal Factor (LF). Stepwise linear regressions and t-tests were performed to compare results from railroad workers (n = 64) with a group of long-term Kars City residents (urban dwellers, n = 16), who had no history of possible contact with anthrax antigens. Anti-PA IgG concentrations were higher (p = 0.038) in railroad workers than in urban dwellers, but anti-LF IgG concentrations did not differ (p = 0.932) between the two groups. The anti-PA response is known to be dominant, and the difference was small. The lack of LF response did not preclude an antibody response to B. anthracis. Following the blasting operations, no cases of anthrax infection occurred in either railroad workers or villagers living nearby, suggesting that the spore exposure (evidenced by higher antibody titres) was at levels insufficient to initiate clinical infection. The elevated PA-specific antibody responses in railroad workers compared with urban dwellers might be consistent with the former having had previous subclinical exposure to B. anthracis. In anthrax-endemic regions, therefore, construction activities that involve blasting or large-scale excavation may pose risks of occupational exposure to Bacillus anthracis spores.